Cervical Cancer: A Call for Prevention

Cervical cancer is the fourth most common cancer affecting women worldwide, and it is the leading cause of cancer-related deaths in women. The WHO projects that the number of cases will increase from 570,000 to 700,000 annually between 2018 and 2030. Along with these increases comes deaths, expected to increase from 311,000 to 400,000 annually.

Women in the developing world bear the burden of cervical cancer, where more than 85% of cases are identified. The main reason is the limited access to screening and early detection.

With the availability of the PAP smear, HPV screen, and HPV vaccination, more than 90% of cervical cancers is preventable. Worldwide efforts to eliminate cervical cancer promote awareness, vaccines, and screening. A woman should not have to find out the hard way that her serious condition was preventable.

“One woman dies of cervical cancer every two minutes…Each one is a tragedy, and we can prevent it.”

Call to Action May 2018. Cervical Cancer: An NCD We can Overcome. Dr. Tedros Adhanom Director-General, WHO

Cervical Cancer: Why do we need to Screen?

Overview

Cervical cancer is a disease in which cells in a women’s cervix go out of control. The cervix connects the upper part of the uterus to the vagina. Every woman is at risk for cervical cancer. It commonly occurs between the ages of 35 and 44.

Cancer of the cervix begins with a small focus and increases in size locally. It may spread to other areas, most commonly local lymph nodes, the lungs, bone, or liver (Zhou, 2020).

Fortunately, cancer of the cervix takes time develop, an estimated 10 to 30 years. That gives doctors a chance to find and treat it before it gets worse. Screening tests for HPV and Pap smears are instrumental in reducing the mortality rate among patients. However, even women who have regular care may miss the opportunity to screen for this type of cancer.

What are the Causes?

The human papillomavirus (HPV) plays an important role in the development of cervical cancer. We now know that HPV is associated with throat, vulvar, anal, penile, and vaginal cancers.

HPV is a sexually transmitted disease that accounts for more than 95% of cervical cancer. The most common type of HPV is HPV 16 – responsible for 50% of cervical cancer.

After someone acquires HPV, more than 90% of infections clear. Most HPV infections never develop into cancer and go away on their own. Certain risk factors, such as HIV, may increase the risk that it does not.

What are the Risk Factors for Cervical Cancer?

HPV infection is the most important risk factor for cervical cancer. Lifestyle, past behaviors, or health issues increases your risk for cervical cancer, especially if you:

  • Infection with HPV
  • Non-vaccinated status for HPV
  • Multiple sex partners, sex before 18, pregnancy before 20
  • Smoke tobacco
  • Have a weakened immune system or taking immunosuppressant drugs
  • HIV – women living with HIV have a 6-times greater risk of developing cervical cancer than those without HIV.
  • Have another sexually transmitted disease (STD)
  • Family history of cervical cancer

Cervical Cancer Prevention and Early Detection

HPV vaccination and cervical screening provide the best chance for prevention and early detection.

The HPV Vaccination

In 2006, the FDA approved of the Gardasil vaccine. Presently, clinics use the updated vaccine, the Gardasil 9. The 9-valent vaccine targets 90 percent of HPV strains that cause cancer. The vaccine includes HPV subtypes 6,11,16,18,31,33,45,52 and 58. The vaccine is approved for boys and girls beginning at the age of nine.

Cervical Cancer Screening

The Pap Smear

The pap smear is a screening test for cervical cancer. It is part of a women’s regular pelvic exam. It involves the collection of a samples from the cervix to look for any concerning cells. 

Consider these PAP smear recommendations:

  • Get a Pap test every three years once you are 21 or older.
  • Get both Pap test and HPV test every five years if you’re 30-65 years old. 
  • No screening is necessary if you’ve had your cervix removed and have no history of cervical cancer.
  • Get tests for chlamydia, gonorrhea, and syphilis once a year if you’re sexually active and have a higher risk for STDs.

After taking the sample, a doctor submits it to a lab. There, a pathologist looks under the microscope for any unusual cells. Cervical cells that appear abnormal get the term “dysplasia.” In some cases, these types of cells may go on to develop cancer.

There are varying degrees of changes, from low to high-grade. Milder changes can sometimes return to normal, as the body recovers. If something shows up on the Pap smear, your doctor will recommend a biopsy of the tissue to examine it more closely. Here is a list of terms of changes, referred to as cervical intraepithelial neoplasia (CIN):

CIN1: This stage is a mild form of changes or a low-grade squamous intraepithelial lesion (LSIL). Most of the tissue remains normal. Doctors recommended close monitoring with PAP smears.

CIN2: A moderate degree of changes exist. This result is called high-grade squamous intraepithelial lesion (HSIL). Doctors usually advise close monitoring, sampling, and treatment.

CIN3: A severe degree of dysplasia exists. This result is called carcinoma in situ (CIS). Further testing and treatment options are advised.

Cervical cancer screening and CIN changes of dysplasia.
Cervix with normal and various levels of changes. Source: Creative Commons. Blausen Med Comm.

HPV Testing

The HPV test can occur at the same as the Pap smear. It involves checking for infection with certain HPV types. The test looks for sub-types that are capable of causing cancer. These include HPV 16, 18, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, 66, and 68.

Tests to Identify Concerning Areas

Colposcopy

When the pap smear identifies unusual cells, colposcopy is a procedure that a doctor may use. First, they apply 5% acetic acid or a dye to the cervix to identify areas that require a biopsy. A colposcope is a camera that magnifies the image of the cervix eight to fifteen times. Using this tool, they look for concerning cells to biopsy.

Colposcopy is a non-invasive procedure that someone can have in a gynecologist’s office. If this procedure shows signs of cancer, they may recommend a cervical or cone biopsy.  

Loop Electrosurgical Excision Procedure (LEEP)

LEEP is a procedure that uses an electrified loop of wire to remove tissue and test it for cancer without surgery. This procedure gives the doctor a better look for types of unusual cells. 

Initially, the approach to high-grade cervical dysplasia or localized cancer (CIS) includes laser therapy, cryosurgery, a cone biopsy, and LEEP.

However, if there is concern for invasive cancer, a work-up must include a staging protocol. A CT scan detects the extent of involvement of local spread, lymph nodes, and whether other organs are involved. From the information, a surgeon can decide on the best direction of care.

Cervical Cancer: A Global Public Health Issue

Readers in the United States may not be aware that the majority of cervical cancer occurs in the poorest countries of the world. Recently, the WHO began a 90-70-90 strategy to address cervical cancer. The effort includes three main goals:

  • First, 90% of girls fully vaccinated for HPV by age 15
  • Second, 70% of women screened by the age of 35 and again at age 45
  • Third, at least 90% of women with cervical disease receiving treatment (WHO, 2020).

The goal for increased screening is to amplify public health efforts. Unfortunately, a strategy to increase vaccination is a challenging effort in these countries. There are logistical and cost restraints. However, a few options may be effective. Firstly, ramping up primary care may allow the opportunity to vaccinate and screen. Additionally, social measures (like women’s groups and cervical cancer survivors) and nongovernmental groups may be pivotal to raise awareness.

cervical cancer cases are highest in parts of Africa, South America and the Pacific.
Source WHO

Concluding Remarks

It is commonly said that “an ounce of prevention is better than a pound of cure.” This advice is all too crucial when someone has a largely preventable disease such as cancer of the cervix.

Here are some recommendations to reduce the risk. Firstly, reduce your risk of getting HPV with safe sex. Next, ask your doctor about if you can get the HPV vaccine. Thirdly, ask your doctor about your PAP test schedule and results.

References

Included in the article as links.

WHO. Global strategy to accelerate the elimination of cervical cancer as a public health problem. 2020.

Zhou S, and Fang Peng. Patterns of metastases in cervical cancer: a population-based study. Int J Clin Exp Pathol. 2020; 13(7): 1615-1623.

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